College of American Pathologists
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  What the Joint Commission will require in
  safety goal 3E:


CAP Today



May 2008
Feature Story

  • A defined anticoagulant management program to individualize the care provided to each patient receiving such therapy.
  • The use of only oral unit dose products and premixed infusions, when these products are available, to reduce compounding and labeling errors.
  • Dispensing warfarin for each patient in accordance with established monitoring procedures, when pharmacy services are provided.
  • Approved protocols for initiating and maintaining anticoagulation therapy appropriate to the medication used, the condition being treated, and the potential for drug interactions.
  • Availability of a baseline INR for patients being started on warfarin, and, for all patients being treated with warfarin, availability of a current INR that is used to monitor and adjust therapy.
  • Notification to the dietary service (if the organization provides such service) of all patients receiving warfarin and response by the service in accord with its established food/drug interaction program.
  • Programmable infusion pumps, when heparin is administered intravenously and continuously.
  • A policy that addresses baseline and ongoing laboratory tests that are required for heparin and low-molecular-weight heparin therapies.
  • Education about anticoagulation therapy for prescribers, staff, patients, and families.
  • Patient/family education that includes the importance of followup monitoring, compliance issues, dietary restrictions, and potential for adverse drug reactions and interactions.
  • An evaluation of anticoagulation safety practices.

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